Basis Of Physical Examination Findings Research Articles

Hypoplastic Left Heart Syndrome: Diagnosis, Care and Management From Fetal Life and Beyond

Hypoplastic left heart syndrome (HLHS) accounts for 2% to 3% of all congenital heart disease but is responsible for 25% to 40% of all neonatal cardiac deaths. Although the exact genetic origins of HLHS have not been clearly defined, various genetic and chromosomal associations have been identified. Advancements in fetal echocardiography have resulted in accurate diagnosis of congenital heart disease. On the basis of physical examination findings, fetuses may be candidates for prenatal intervention. In general, after prenatal diagnosis of HLHS, parents are faced with 2 choices: termination or continuation of pregnancy. If pregnancy is continued to delivery, patients may choose comfort care, surgical palliation with the Fontan procedure, or transplantation. A once lethal congenital anomaly, HLHS has undergone a marked evolution in management and prognosis during the last several decades. With advancements in prenatal diagnosis, neonatal management, and surgical palliation, patient survival has drastically improved: at an experienced center, current survival rates are very high after the Norwood procedure, with high rates of overall freedom from death or transplantation through 20 years. With survival becoming more promising, the issues that now take precedence are neurodevelopmental outcomes, Fontan procedure complications, and quality of life. Although much progress has been made in caring for this patient population, HLHS remains a high-risk condition that requires lifelong medical follow-up and has significant long-term morbidity, affecting overall quality of life for patients and their families.

Evaluation of plasma fibrinogen concentration as a diagnostic indicator of inflammation in red-eared sliders (Trachemys scripta elegans).

To critically evaluate plasma fibrinogen concentration as a diagnostic indicator of inflammation in red-eared sliders (Trachemys scripta elegans). Prospective induced-disease model and prospective cross-sectional study. Plasma samples from 12 purpose-bred red-eared sliders and 153 farm-raised red-eared sliders. A modification of the Jacobsson method was developed to measure fibrinogen concentration in platelet-poor plasma from red-eared sliders. Purpose-bred turtles had been inoculated with a ranavirus (n = 4) or sterile PBS solution (8) as part of another study. Farm-raised red-eared sliders were categorized as healthy (n = 138) or overtly ill (15) on the basis of physical examination findings at the time of blood sample collection. Samples from 124 of the 138 healthy red-eared sliders were used to establish a fibrinogen concentration reference interval as measured by the modified Jacobsson method. Fibrinogen concentrations in ranavirus-infected and physically ill turtles were compared with those of healthy turtles to determine whether fibrinogen concentration would be a useful diagnostic indicator of inflammation in red-eared sliders. The modified Jacobsson method was reliably used to measure fibrinogen concentration. The fibrinogen concentration reference interval from healthy reproductively active female red-eared sliders was right skewed. Fibrinogen concentration did not differ significantly between healthy red-eared sliders and ranavirus-infected or overtly ill red-eared sliders. A reference interval for red-eared slider plasma fibrinogen concentration was established and partitioned by sex to account for considerable right skewing observed for females. Fibrinogen concentration was not a useful indicator of inflammation in red-eared sliders with ranavirus infection or other overt illnesses.

Tick Tock

Tick Tock

Avulsion Fracture of the Lateral Ankle Ligament Complex in Severe Inversion Injury

Background Avulsion fracture of the lateral ankle ligaments is often undetected on early radiographs. The epidemiology and treatment of such avulsion fractures have received much less attention than the epidemiology and treatment of rupture of these ligaments. Hypothesis The clinical characteristics of avulsion fracture are different from those of ligament rupture. Unlike nonoperative treatment of lateral ligament rupture, nonoperative treatment of avulsion fracture does not yield satisfactory results. Study Design Cohort study; Level of evidence, 2. Methods A total of 169 consecutive patients with severe inversion injury were classified into a ligament rupture group or avulsion fracture group on the basis of physical examination findings and anterior talofibular ligament and calcaneofibular ligament radiographic views. Age, sex, activity level, and the mechanism of injury were analyzed. Patients in both groups were treated by casting. Follow-up examination of 152 patients included clinical assessment and functional evaluation based on the Karlsson system. Results Avulsion fracture was diagnosed in 44 (26%) of the 169 patients and was most common among children and patients over 40 years of age. Sedentary level activity and low-energy injury were more common in the avulsion fracture group than in the ligament rupture group (77% vs 37%, respectively, P = .001; 68% vs 43%, respectively, P = .004). Nonoperative treatment of avulsion fracture (mean Karlsson score, 89.1 points) yielded satisfactory results that were comparable with those of nonoperative treatment of ligament rupture (mean Karlsson score, 88.4 points) (P = .123). Osseous union was achieved in 65% of the patients with avulsion fracture. Conclusion Avulsion fracture of the lateral ankle ligaments in cases of severe inversion injury is more common than previously believed. Because of the high incidence and difficulty of detection in children, a high level of suspicion is necessary in order to obtain an accurate diagnosis of avulsion fracture in cases of severe inversion injury and to achieve adequate stability.

Vascular Mapping of the Leg with Multi–Detector Row CT Angiography prior to Free-Flap Transplantation

To retrospectively evaluate multi-detector row computed tomographic (CT) angiography in determining donor- and recipient-site arterial suitability for successful vascularized free-flap transplantation. The institutional review board granted approval; informed consent was waived, and the study was HIPAA compliant. Lower extremities of 20 (12 male, eight female; mean age, 51 years; range, 10-84 years) patients undergoing vascularized free-flap procedures were examined at multi-detector row CT angiography. In five patients, legs were assessed as potential fibular free-flap donors for mandibular, maxillary, or radial reconstruction. In 15 patients, legs were assessed as recipient sites for free flaps. Vascular maps obtained with volume rendering, maximum intensity projections, and curved planar reformations were generated, and assessment was made in the depiction of calf vessels and presence of stenosis, occlusion, and anatomic anomaly. Findings of CT angiography, physical examination, and surgery were compared, where applicable, and successful CT-based prediction of the surgical intervention was assessed. Immediate and long-term (>70 days) viability of the graft was assessed in all patients. CT angiography depicted the entirety of all four major calf arteries in 29 of 32 legs scanned. In three legs, external-fixation hardware obscured some segments. There were no discrepancies between CT findings and those identified at the time of surgery. Arterial abnormalities, including stenosis, occlusion, and variant anatomy, were seen in 12 lower extremities in 10 patients. Only two were suspected on the basis of physical examination findings. In five of 20 patients, CT findings resulted in changes to the surgical plan. There was a 100% immediate viability of all grafts, which remained well vascularized between 70 days and 37 months after the procedure. Multi-detector row CT angiography provides a noninvasive means of preoperatively assessing lower extremity arteries for abnormalities, which could jeopardize graft viability or pedal arterial supply after free-flap procedures.

Cystoscopic light test to aid in the differentiation of high-grade pelvic organ prolapse

It remains quite difficult to distinguish a high-grade cystocele from an enterocele or high rectocele on the basis of physical examination findings alone. We have employed the use of a cystoscopic light test during preoperative or intraoperative endoscopy to assist in differentiating these entities.

Effects of choreito and takushya consumption on in vitro and in vivo struvite solubility in cat urine

Abstract Objective To determine the effects of the takushya portion of choreito, a traditional Chinese treatment for urolithiasis, on urine and struvite crystal variables in cats fed diets containing takushya. Sample Population 6 male and 6 female adult cats, all considered to be clinically normal on the basis of physical examination findings, results of CBC, serum biochemical analyses, urinalyses, and urine cultures; and freedom from urolithiasis on the basis of urethrocystoscopic (females) or urethrocystographic (males) findings. Procedure Cats were fed a commercial canned diet supplemented with 0.1-mg of takushya/kg of body weight, or with 0.5 mg of choreito/kg. Diets were fed, using a Latin-square design, to 3 groups of 4 cats (2 male, 2 female) each for 2 weeks, followed by blood and 24-hour urine sample collections. Results Consumption of takushya, which comprises 20% by weight of choreito, was not associated with adverse effects in cats at the amounts provided during the period of study. Moreover, takushya was responsible for most of the effect of choreito consumption on reduction of urine pH, and approximately half its ability to reduce struvite crystal formation in cat urine. Clinical Relevance Alternative treatments for struvite urolithiasis in cats may be feasible. (Am J Vet Res 1997;58:150–152)

Effects of choreito consumption on urine variables of healthy cats fed a magnesium-supplemented commercial diet

Abstract Objective To investigate the effect of choreito consumption (500 mg/kg of body weight/d) on struvite crystal formation and signs of lower urinary tract disease (LUTD) in cats consuming a commercial canned diet with 0.5% added inorganic magnesium. Sample Population 6 male and 6 female adult cats, all considered to be clinically normal on the basis of physical examination findings; results of CBC, serum biochemical analyses, urinalyses, and urine cultures; and freedom from urolithiasis on the basis of urethrocystoscopic (females) or urethrocystographic (males) findings. Procedure Diets were fed for 12 weeks, or until appearance of signs of LUTD, including dysuria, hematuria, urine pH > 7.0, and severe struvite crystalluria. Presence of at least 2 of these signs was required for removal from study. Urine specimens were examined for electrolytes, struvite crystal content, and hematuria. Results Results for urine variables were compared between groups at 4 weeks, because of reduction in cat numbers attributable to removal from study. Struvite crystal content of 24-hour urine specimens was significantly lower for cats fed the choreito-containing diet. Moreover, frequency and severity of hematuria were significantly decreased in cats fed the choreito-containing diet. Correlation between hematuria and struvite crystal content was not observed in either group. Additionally, all 6 cats fed the diet without choreito had been removed from study by day 58 because of signs of LUTD. Of the 6 cats fed the choreito-containing diet, 2 completed the 12-week study. Clinical Relevance Choreito may be beneficial for relief of some signs of struvite-associated LUTD disease in cats. (Am J Vet Res 1997;58:146–149)

Comparison of peritoneal fluid analysis before and after exploratory celiotomy and omentopexy in cattle

Summary The effect of right paralumbar fossa exploratory celiotomy and omentopexy on peritoneal fluid constituents was studied in 22 adult dairy cows. Six cows were eliminated on the basis of physical examination findings (n = 2), surgical findings (n = 2), or inability to obtain a sufficient volume of peritoneal fluid (n = 2). Sixteen cattle had normal results of cbc and serum biochemical analysis, and a minimum of 1 ml of peritoneal fluid was obtained by abdominocentesis. Abdominocentesis was repeated on days 1, 2, and 6 after surgery. Statistical analysis for repeated measures was performed, using a significance level of P < 0.05. Stage of gestation was evaluated for interaction with time. Mean total nucleated cell count was 3,200 cells/μl before surgery, was significantly increased 2 days after surgery (16,336 cells/μl), and continued to increase through day 6 (20,542 cells/μl). Mean polymorphonuclear cell count was 1,312 cells/μl before surgery and was significantly higher at 2 (11,043 cells/μl) and 6 (10,619 cells/μl) days after surgery. Mean lymphocyte count was 254 cells/μl before surgery and was significantly increased 2 days (1,911 cells/μl) after surgery. By day 6, lymphocyte numbers were similar to preoperative values. Mean mononuclear cell count was 770 cells/μl before surgery and was significantly increased on days 1 (3,084 cells/μl), 2 (3,285 cells/μl), and 6 (2,349 cells/μl) after surgery. Mean eosinophil numbers were 1,388 cells/μl before surgery and were significantly increased on day 6 (6,347 cells/μl) only. Interaction between time and stage of gestation was found only for specific gravity and total protein concentration. In general, specific gravity and total protein concentration increased after surgery (mean before surgery, 1.016 and 3.6 g/dl; mean after surgery, 1.021 and 5.6 g/dl). Left paralumbar fossa celiotomy performed 7 days after surgery did not reveal complications of repeated abdominocentesis, and pregnancy status was unchanged. Peritoneal fluid constituents are highly variable after exploratory celiotomy and omentopexy in cattle. However, results of this study may provide a reference for interpretation of postoperative peritoneal fluid sample findings in cattle.

Effects of choreito consumption on struvite crystal growth in urine of cats

Summary The effect of a dietary supplement, choreito, on in vitro struvite crystal growth in feline urine was evaluated. Adult specific-pathogen-free cats (4 females, 4 males) considered to be clinically normal on the basis of physical examination findings and normal results of cbc, serum biochemical analyses, and urinalyses obtained before the beginning of the study were used. Before 24-hour urine sample collections were made, cats were fed a commercial canned diet with 0 or 500 mg of choreito supplement/kg of body weight for at least 2 weeks in a cross-over design with 4 cats/treatment. Filtered urine samples were analyzed for urine pH, specific gravity, osmolality, and urine electrolytes. The struvite activity product was calculated, using a statistical software program that calculates urine saturation. Urine samples were placed in wells of cell culture plates, increasing concentrations of ammonium hydroxide were added to adjacent wells to stimulate struvite crystal growth, and the plates were incubated at 37 C. Crystal growth was assessed by determination of number of crystals and supersaturation index by direct visualization, using an inverted microscope. Supplementation of the diet with choreito (at this concentration) did not change urine pH, specific gravity, osmolality, urine electrolyte composition, or calculated struvite activity product. However, supplementation significantly (P < 0.05) reduced crystal number and supersaturation index. These results indicate that direct observation of struvite crystal formation in whole urine may more accurately predict the effects of treatments to prevent or treat struvite urolithiasis than do calculations based on electrolyte concentration that do not account for the effect of urine macromolecules. It also may mean that choreito consumption affects the concentration of inhibitors or promoters in urine. It was concluded that choreito significantly (P < 0.05) reduced growth of struvite crystals in feline urine, and thus may have a role in prevention of feline struvite urolithiasis. In vivo studies will be necessary to test this hypothesis.

Cor de Ballet

Lest, carried away by our imagination, we read into the title "The Heart of a Dancer"¹allusions to a great love affair in the life of a celebrated prima ballerina or a renowned male ballet star, the subtitle promptly reminds us that what it is all about is not romance but "the noninvasive cardiac evaluation of professional ballet dancers." This reminder may come as a bit of a jolt. We are accustomed to viewing dancers as artists in need of appreciation rather than as athletes in need of cardiac evaluation. To assess the effect of ballet training on the heart, Cohen and associates¹compared some basic cardiovascular variables in 30 (15 women and 15 men) American Ballet Theatre dancers with those in 15 matched sedentary control subjects. On the basis of physical examination findings, echocardiography, phonocardiography, and ECGs, they established statistically significant differences. Male dancers, for instance, had